Preventing Osteoporosis: What Every Woman 40+ Needs to Know

What is osteoporosis and how does it develop?

Your bones may seem static, but they are constantly in motion. Every day, specialised cells (osteoclasts) break down old bone tissue, while other cells (osteoblasts) build new bone. This process is called bone remodelling and ensures that your skeleton stays strong and healthy. Up to around your 30th year, building wins out over breakdown: your bone density increases. Around your 35th you reach your peak bone mass — the maximum point of bone density in your life.

After that, the balance slowly tips. Breakdown occurs faster than building, and you gradually lose bone mass. For most people this happens so slowly that it causes no problems. But in some women, this process accelerates dramatically — especially around the menopause. The bone becomes more porous, thinner and more brittle, like a sponge whose holes are getting ever larger. This is osteoporosis: literally 'porous bone'.

The treacherous thing about osteoporosis is that you don't feel it. There are no pain complaints, no warning signals. Many women only discover it when they break a bone in a relatively minor fall: a broken hip, wrist or compressed vertebra. At that point, bone loss has been occurring for years. This is why osteoporosis is also called the 'silent disease'.

Why women are at extra risk

The figures speak for themselves: an estimated 1 in 3 women over 50 will experience an osteoporotic fracture. For men, that's 1 in 5. Women are at extra risk for several reasons.

Oestrogen: the great protector of your bones. Oestrogen inhibits the activity of osteoclasts — the cells that break down bone. As long as your oestrogen level is adequate, your bones are protected. But during perimenopause and menopause, your oestrogen drops sharply. That protection largely disappears. In the first five to seven years after menopause, women can lose up to 20% of their bone density. That's an enormous loss in a short time.

Women start with less bone mass. Women naturally have a smaller and lighter skeleton than men. The peak bone mass reached around the age of 35 is on average lower. This means there is less 'reserve' when bone loss begins. You're starting, as it were, with a smaller balance in your bone bank.

Lifelong factors play a role. Pregnancies, breastfeeding, periods of strict dieting or eating disorders, and prolonged use of certain medications: these are all factors that can additionally burden women's bone density. Many women have already gone through several of these periods before the menopause begins.

The most important risk factors

Some risk factors you cannot change, others you can. It's important to know your own risk profile so you can take targeted action.

Non-modifiable risk factors:

• Age: the older you get, the more bone mass you lose.
• Female sex: women lose bone mass faster, especially after the menopause.
• Early menopause: if your menopause begins before age 45, you're at extra risk due to longer exposure to low oestrogen levels.
• Family history: if your mother or grandmother has had a hip fracture, your risk is elevated.
• Body type: slim, light women have on average less bone mass.

Modifiable risk factors:

• Too little calcium and vitamin D: your bones don't receive enough building materials.
• Insufficient movement: especially a lack of weight-bearing activities such as strength training.
• Smoking: accelerates bone loss and reduces calcium absorption.
• Excessive alcohol consumption: more than two glasses per day significantly increases the risk.
• Crash diets and not eating enough: prolonged calorie deficit leads to bone loss.
• Too little protein: bones are one third protein.
• Prolonged medication use: in particular corticosteroids (prednisone) increase the risk.

The good news? Most of the risk factors threatening your bones are the same ones you can tackle yourself. And that's where the real story begins.

Nutrition for strong bones

Your bones need building materials every day. Without the right nutrients, your body simply cannot build strong bone tissue — regardless of how much you train. These are the most important nutrients for your bones:

Calcium: the foundation

Calcium is the most important mineral in your bones. About 99% of all the calcium in your body is in your skeleton. Adult women need 1000 to 1200 mg of calcium daily. The upper end is recommended during and after the menopause.

The best calcium sources from food:

• Dairy: a glass of milk (200 ml) contains about 240 mg of calcium. Yoghurt, cottage cheese and cheese are equally excellent sources. 30 grams of mature cheese already provides around 300 mg.
• Green leafy vegetables: kale, broccoli, pak choi and spinach contain calcium, although absorption from some vegetables (like spinach) is lower due to oxalate.
• Nuts and seeds: almonds, sesame seeds and chia seeds are surprisingly good calcium sources. Two tablespoons of tahini (sesame paste) contain around 130 mg of calcium.
• Fish with soft bones: canned sardines and salmon (with bones) provide plenty of calcium.
• Fortified plant-based drinks: soya milk and oat milk with added calcium are good alternatives to dairy.

Vitamin D3: the key to absorption

Without vitamin D, your body can barely absorb calcium from your intestines. In the Netherlands, from October to March we receive insufficient sunlight to produce vitamin D ourselves. The Netherlands Nutrition Centre advises women over 50 to supplement daily with 20 micrograms (800 IU) of vitamin D. But women between 40 and 50 are also wise to have their vitamin D level checked, especially if they spend little time outdoors or have a darker skin tone.

Vitamin K2: the traffic controller

Vitamin K2 is less well known but equally important. It activates proteins that ensure calcium actually ends up in your bones — and not in your blood vessels. Vitamin K2 is found in fermented products such as natto, certain cheeses (gouda, brie) and egg yolk. Many good vitamin D supplements also contain K2, and that's not without reason: they work synergistically.

Magnesium: the forgotten hero

About 60% of the magnesium in your body is in your bones. Magnesium helps with the conversion of vitamin D to its active form and is needed for the functioning of parathyroid hormone, which regulates your calcium levels. Good magnesium sources are nuts (especially cashews and almonds), dark chocolate, wholegrain products, avocado and green vegetables.

Protein: the building frame

What many women don't know: your bones don't consist only of minerals. About one third of your bone tissue is collagen — a protein that forms the flexible frame to which minerals attach. Without enough protein, your bones don't only become weaker, but also more brittle. Aim for at least 1.2 grams of protein per kilogram of body weight per day, distributed across your meals.

Movement: the most powerful protection

Alongside nutrition, movement is the most effective way to keep your bones strong. But not every form of movement is equally valuable for bone density. Your bones respond to load: the more mechanical force you exert on your skeleton, the stronger your bones become. This principle is known as Wolff's law: bone adapts to the load placed upon it.

Strength training: the gold standard

Strength training is by far the best form of movement for your bones. When your muscles pull on your bones during lifting weights, your osteoblasts respond by producing more bone tissue. Research consistently shows that women who do strength training two to three times per week can improve their bone density in the hip and spine by 1 to 3% per year. By comparison: without training, you actually lose bone mass in the same period.

Importantly, the load must be heavy enough. Light weights of one kilogram have barely any effect on your bones. Work towards weights that truly challenge you, where the last repetitions take effort. Compound exercises such as squats, deadlifts, lunges and overhead presses are most effective because they load multiple bones and muscle groups simultaneously.

Impact training: bones love shocks

Alongside strength training, bones respond excellently to impact — brief shocks that pass through your skeleton. Think of:

• Jumping: jumping off a low platform, jumping jacks or skipping rope.
• Walking and jogging: the repeated impact at each step stimulates your bones, especially in your legs and hips.
• Stair climbing: a simple but effective way to get daily impact.
• Dancing: the combination of impact, changes of direction and coordination is excellent for your bones.

Note: if you already have reduced bone density (osteopenia or osteoporosis), first consult your GP or physiotherapist about which forms of impact are safe for you. High-impact activities are not suitable for everyone.

Balance training: fall prevention is bone prevention

Most osteoporotic fractures result from a fall. Balance training is therefore at least as important as strength and impact training. If you don't fall, you don't fracture — no matter how low your bone density is. Effective balance exercises include:

• Standing on one leg (for example, while brushing your teeth).
• Heel-to-toe walking in a straight line.
• Exercises on an unstable surface, such as a balance board.
• Tai chi, proven effective in reducing fall risk in older adults.

At FEM Rebalance, we combine strength training with balance and stability exercises. This way you work not only on stronger bones, but also on the coordination and muscle strength you need to stay firmly on your feet.

What to avoid

Alongside what you can do for your bones, it's equally important to know what causes them harm. Some habits that women often consider harmless can be devastating for bone density in the long term.

Crash diets and prolonged under-eating. This is one of the greatest threats to women's bones — and one that receives too little attention. When you take in too few calories for an extended period, your body goes into a kind of survival mode. It scales back processes that are not immediately necessary for your survival, and bone building is one of them. Furthermore, strict dieting lowers your oestrogen level, which accelerates bone loss even further. Many women who have yo-yo dieted for years have unknowingly damaged their bone density.

Smoking. Smoking accelerates bone loss in multiple ways. It reduces blood supply to your bones, disrupts calcium absorption, lowers oestrogen levels and inhibits the activity of osteoblasts. Women who smoke have on average a significantly lower bone density than non-smokers and reach menopause earlier.

Excessive alcohol. An occasional glass of wine is no problem, but more than two glasses per day significantly increases the risk of osteoporosis. Alcohol disrupts the calcium balance, inhibits the production of new bone tissue and also increases your fall risk — a combination that hits your bones twice over.

Too much salt and caffeine. A high salt intake increases calcium excretion through your kidneys. And while a few cups of coffee per day are no problem, excessive caffeine use (more than four cups per day) can reduce calcium absorption. Compensate by eating enough calcium-rich food.

Prolonged sitting. Your bones need load to stay strong. Those who sit a lot and move little lose bone mass faster. Even if you exercise three times per week, it's important to stay active throughout the day: get up regularly, take the stairs and go for short walks.

The DEXA scan: when to get one?

A DEXA scan (Dual-Energy X-ray Absorptiometry) is the gold standard for measuring bone density. It's a quick, painless measurement that uses a low dose of X-rays to determine the mineral density of your bones — usually in your hip and lumbar spine. The result is a T-score:

• T-score above -1: normal bone density.
• T-score between -1 and -2.5: osteopenia (reduced bone density, a precursor to osteoporosis).
• T-score below -2.5: osteoporosis.

When to get one? Guidelines recommend a DEXA scan if you are 50 or older and have one or more risk factors, such as an early menopause, family history, prolonged use of corticosteroids, a previous fracture from minor trauma, or if you smoke. Some doctors advise a baseline measurement around the menopause as a reference point, so you can compare later.

Ask your GP for a referral if you think you're at risk. It's a simple investigation that can relieve a great deal of concern — or give you the motivation to take action today.

Your action plan for strong bones

You don't need to change everything at once. Strong bones are built with consistent, daily choices. Here is a concrete action plan you can start today:

Step 1: Get your nutrition in order

• Ensure at least 1000-1200 mg of calcium per day through food (2-3 portions of dairy or fortified alternatives, supplemented with vegetables, nuts and fish).
• Take a daily vitamin D3 supplement (800-1000 IU), especially from October to April. Have your blood level checked.
• Consider a vitamin K2 supplement, especially if you're already taking vitamin D.
• Eat enough protein: at least 1.2 grams per kilogram of body weight, distributed throughout the day.
• Eat magnesium sources: nuts, seeds, wholegrains and green vegetables.

Step 2: Start strength training

• Start with two sessions per week, preferably with guidance to learn the technique properly.
• Focus on compound exercises: squats, deadlifts, lunges, rows and presses.
• Gradually build up to heavier weights. Your bones need sufficient load to become stronger.
• Add impact exercises: stair climbing, walking, light jumping.

Step 3: Work on your balance

• Practise standing on one leg for 2 minutes daily (left and right).
• Do targeted balance exercises weekly as part of your training.

Step 4: Eliminate the threats

• Stop smoking, or seek help to quit.
• Limit alcohol to a maximum of one glass per day.
• Avoid crash diets. Never eat structurally less than your body needs.

Step 5: Get your bone density measured

• Discuss with your GP whether a DEXA scan is worthwhile, especially if you have risk factors.
• Use the result as a baseline measurement to track your progress.

Your bones carry you literally through life. They deserve the same attention as your muscles, your heart and your hormones. The beautiful thing is: everything you do for your bones — eating well, moving powerfully and living healthily — also makes you fitter, stronger and more energetic. It's not a sacrifice; it's an investment in a future where you remain active, independent and vital.